Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Thursday, November 08, 2007

One of my PET PEEVES (and yes, there are a lot of them) is blood pressure. We get these people all day long sent to the ED because their blood pressure is "high". A few weeks ago, the dental assistant wasn't going to even let me see my dentist because I hadn't taken my meds that day and I don't like dentistry....so my pressure was 167/101.

Tonight, I had a typical scenario. A patient with blood pressures ranging from 170's / 100's was sent to the ED by his chiropractor. Turns out that they guy's arms had been tingling for 2 weeks (coincidentally about the same time the chiropractor started using some traction device that stretches the guy's neck). But TODAY, his blood pressure was high and he was rushed to the ED.

Of course, every headache patient has an elevated pressure, and most of the "total body tingly" patients have an elevated pressure. Our nurses freak out when I try and discharge anybody with a high pressure, and one local EMS service even gives sublingual nitroglycerine to anybody with an elevated pressure! I just don't get it.

Hasn't the evidence been pretty clear for about 15 years that urgent treatment of blood pressure is dangerous and contraindicated? (unless the diastolic is over about 130 or there is any evidence of end organ damage).

I get concerned when the patient has chest pain, shortness of breath, or neuro symptoms, but otherwise, I couldn't care less about the blood pressure. It's an outpatient workup, and treatment.

I try to educate patients, but I might as well try and educate the shrub in my front yard.

I get these people all day long who check their blood pressure 6 times a day and come to the ED the minute one reading is "high". By the time I see them, they've convinced themselves that they have all kinds of symptoms, and the blood pressure just must be the cause.

What do you guys do? (I don't mean Etotheipi.....I'd assume 0/0 is his normal patient).

I see my pcp for my bp! Even when it goes high. My obgyn asked my pcp to change my bp meds for trying to get pregnant. My bp went sky high. I didn't go to the ER, I called my PPC. She had me come in, evaluated and back on to the old med I went. Which was determined is ok for pregnancy, not just the best one.

The only time anyone freaked about my bp was when I was pregnant. They harassed my dr 10 times a day about it. He kept telling them, you don't understand. She was running a higher pressure before delivery w/2000mg aldomet and 60mg of procardia. I took her off all meds to see what it would do. This is good because it is not going higher. The nurses just didn't get it and were very uncomfortable with it. Eventually I went back on meds but still.

if i'm in a good mood or have time i give my "blood pressure is analogous to the pressure in your plumbing system... over time blah blah blah" at which point their blood pressure is decreased due to boredeom.

Being any internist, I, too, am the recipient of patients with blood pressure "emergencies". They are sent over to be worked in that day by their dentist/surgeon/chiropractor with an elevated blood pressure but no symptoms. It seems that these practitioners just want them out of their office as quickly as possible.

I usually wind up doing nothing acutely. I take the episode into consideration at their follow up visit and adjust medication if necessary.

I love it when their B.P. is high and it's *suddenly* a big deal and then when you go over their meds and find out they are on meds for their B.P. they say 'oh I didn't feel like it was high so I didn't take them/refill them' but it's suddenly a crisis now? grr.

treatment of htn on the EMS side is fraught with difficulties. our system doesn't treat without symptoms and even then it's a call in order as the proper med is dependent on the symptoms. that being said, chest pain with a pressure that will support nitro is given nitro.

I'm with the treat/workup if there are symptoms of end-organ damage (altered mental status, headache...maybe, chest pain, shortness of breath, neuro symptoms), and the "let me tell you about blood pressure...." discussion if not.

Glad to know I'm not on an island alone. Some of my partners (FP trained) won't let a patient leave the ED unless their BP is normal "because they might have a stroke and then we're liable". I've never seen the point of making the number look good for discharge and sending the patient out with no treatment for blood pressure. This duality of treatment opinions just confuses our nurses.I appreciate the internist perspective and enjoyed the link.

I actually get a patient sent to the ED about once a month from a PCP's office for asymptomatic hypertension. Usually at 5:15, with a long list of BP meds, a longer handwritten list of 24 time per day BP readings, and a nice note by the PA/NP.

No symptoms except anxiety. I usually prescribe no more than two BP checks a day, and some reasurrance (barring other symptoms, etc).

As a PCP, I see these people in the office and have long-winded circular conversations about it being important to control your BP on a long-term basis but that a few high readings are generally not something to worry about.

I answer lots of questions which prove that they can't hear me.

Then I forbid them from checking their BP more than twice a week. Whoever invented the home BP monitor should be shot.

I always tell patients that if they're in enough distress for some other reason to come to the emergency department, that it's ok if their BP is a bit high, because of pain/paranoia/white coat htn, etc, and just to monitor for other symptoms and follow up the next day or 2 with their PCP if they're still concerned.

where I draw the line is when the patient comes in after talking to their PCP, who negligently sends them to the emergency department to be worked up for the hypertension, which is something that can be done as an outpatient by a competent physician. what? you think i'm going to get the plasma renin level back any faster than you, considering it's a send out? or my pheo workup is going to pan out any differently?

see, now i just worked myself up into a mood. now i know why this is the best blog in the medicoblogosphere!

I simply tell them I can make their blood pressure normal, but the trade off will be getting around in a wheelchair, having a rubber tube stuck in your urethra, and not moving one side of your body when you have that stroke due to dropping your pressure too fast. Most are fine to leave at that point.

The best way to treat these pts, besides telling them the dr who sent in is, (well I won't go there right now) to give your nurse 10mg of Valium..Y'all know I love my ED nurses, but I don't have freakin' clue what they are taught in nursing school about HTN!!!But clearly they are taught something different than we are!

i don't discharge my patients unless their bp is 120/80. it takes some neat alternating doses of clonidine and fluid boluses to get it just right then we turn off the monitor and discharge the patient immediately.

I don't have freakin' clue what they are taught in nursing school about HTN!!!

We're taught what BPs are important in what situations (eg. fever and BP of 60/40 or htn/brady/irreg breathing or BP of 190 in a new embolic stroke patient=good or BP of 190 in intracranial bleed patient=bad) and possible or common treatments thereof. Then the usual education about what htn is a risk factor for. I don't think I was specifically taught when to NOT intervene in the face of abnormal vital signs; that's sort of the whole nursing judgment thing.

The new nurse is supposed to be able to identify abnormals, evaluate if the abnormal is significant for that patient, and what to do about it.

Sometimes I will officially ask if we need treatment for an abnormal blood pressure so I can document that I asked, not necessarily thinking anything needed to be done.

k: You clearly went to an excellent nursing school. We have 2 nursing schools in my town, and 1 in each of my previous practice locations. They were all taught that high blood pressure was immediately bad....not the situational interpretation (which is correct).

The lack of consistency among the way the docs deal with the issue seems to contribute to the confusion.

Unless I am working with a seasoned crew, I find myself uttering the phrase "I don't care what his blood pressure is, he has a broken XXXX" at least three times a week.

Here's the analogy I use...."if you were walking to your car tonight after your shift and I jumped out from behind a tree with a knife and screamed.....would it then be appropriate medical care for me to start you on beta blockers for your elevated heart rate? "

i'm allergic to droperidol and haldol and i have prolonged QT and i'm allergic to nsaids and tylenol and geodon. last time they gave _____(insert non narcotic medicine here) to me i nearly died and my throat closed down on me and exacerbated my chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and borderline personality disorder. so really, the only thing that works for me is dilaudid and a stiff double shot of fine scotch. will be by soon to see you.

i'm allergic to droperidol and haldol and i have prolonged QT and i'm allergic to nsaids and tylenol and geodon. last time they gave _____(insert non narcotic medicine here) to me i nearly died and my throat closed down on me and exacerbated my chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and borderline personality disorder. so really, the only thing that works for me is dilaudid and a stiff double shot of fine scotch. will be by soon to see you.

I also had to study and test on reflexology and learn and demonstrate the fundamentals of 'healing touch' and 'the M technique.' I always thought the M technique sounded like some sort of dirty maneuver to achieve an orgasm, but it was less exciting than that. The unit on aromatherapy was also tremendously beneficial. Or something.

Of course, most of us wanted more than a 1-time practice on IVs and basic skills like that, but it was better in the long run that I could manipulate the energy fields of my patients rather than quickly and effectively insert an IV in a time of need.

"Should I insert the IV and hang this life-saving antibiotic or just run my hands over their body? I'm confused."

Most nursing is learned after you work, but I at least knew how to not kill someone or, more difficultly, let them die or get much worse due to inaction.

And, in nursing school, pain is what the patient says it is, patients are never drug-seeking losers.

nurse K, in all seriousness. either go to med school, get your NP, or go make a million dollars doing something else. i agree with erdoc85 that something in your background has made you exceptional. you have managed to increase your clinical judgement and skills in spite of the primacy of paperwork skills in today's nursing schools. please let us know when you get back up in the blogosphere, and, in the meantime, consider this blog your home away from home. also, if you need any soprano-like assistance with your arch nemesis then DRX may be able to assist.

I switched away from medical skool idea when I got knocked up at an inopportune time in my life. I was a pretty damn good neuroscience undergraduate student prior to the imminent need to graduate and make money ASAP rather than fartin' along in academia for another 8 years.

It would be a disservice to my son to go to medical skool at this point (or really any point), but in perhaps another couple of years, I'll go get my NP so primary care doctors can tell me I'm merely another indicator that the fall of the primary care physician is around the corner or something. I've also considered the MHA program in town so I can carry my clipboard around and yearn to resuscitate someone again.

I know what you mean, but understand that the fact that I went into nursing isn't a disappointment nor an indication that I have failed.

dear nurse K, you misunderstand me. you are a credit to the nursing profession and individual nurses have my respect until they do a bunch of stuff to lose it. i merely mean that with the focus on clipboard nursing you must want to scream. at least on the 'provider' side we have a bit more autonomy, though less and less every day due to aforementioned paper people. i would strongly advise my kids against med skool and anyone who asks about it i try to steer in other directions. as Oldfart has mentioned recently, i love my nurses, they save my ass every day and save lives every day. i am not impressed with myself because of the letters after my name, i am impressed with myself because of my gargantuan penis.

i merely mean that with the focus on clipboard nursing you must want to scream.

I get riled up for the following reasons: (1) Too many patients (real patients, that is) vs. too few beds (2) Too many BS patients trolling for narcotics and being verbally abusive to me (3) Certain combinations of doctors and nurses which could be considered 'the perfect storm' (4) Holding patients in the ER for hours on end due to "budgetary concerns" which preclude staffing the hospital adequately for admits while we're working short too (5) Doctors who treat me like I'm a retard or who over-treat BS or minor complaints beyond the point of reason, especially during a #1 type of situation

i am impressed with myself because of my gargantuan penis.

So that explains the excessive overuse of lower case letters. You're attempting to achieve equilibrium between large and small.

K: We're complimenting you. You have obviously got the savvy that ER docs love to work with.Were it not for good nurses, I could not begin to do my job. I just have to know who they are and who they aren't. Our hospital is dealing with shortages by hiring lots of GN's. Of the 10 or so hired in the last year, only 1 is worth her weight in formalin swimming maggots. I think you should have to spend a year on the wards before you get to the ED.

Used to be that the CERN was a big deal and those were always our best nurses. But the test is hard, it's expensive, and it doesn't get you any more pay...so it seems like nobody takes it any more.

I agree with you. Most nurses learn the important stuff after nursing school. (hell, medical school didn't make me into a competant doctor...residency did that). No human being is more idiotic than an RN, PhD. I have met more than my share of those folks. They have constant rainbows shooting out of their asses. But they couldn't draw a blood specimin from a vein the size of my finger.

And P.S. I have worked with NP's. My opinion would have been different had I not had lots of involvement with them, but I think they are great. Most are smart, caring, and reasonable.

They have constant rainbows shooting out of their asses. But they couldn't draw a blood specimin from a vein the size of my finger.

Oh, certainly. Try sitting through any nursing lecture ever. I couldn't decide whether to laugh or cry half the time. To make things worse, they are all hardcore socialists too. What's worse than a rainbow-out-of-your-ass ivory-tower communist who can't start an IV nor rapidly assess and treat a patient? NOTHING. They'd be the perfect nurses for a 3rd world communist regime, in fact.

The PhD nurse would be evaluating the patient's home living conditions and psychosocial stressors rather than, like, pushing the amp of epi during the v-fib. Meanwhile, I'm arguing about the necessity to assess and treat skin integrity RIGHT THIS SECOND while yelling out heart rhythms and compressing the chest.

Do you mean you weren't on your back?

What is this back stuff you're talking about? I ain't no Amish. Do people really do that anymore? Huh.

From the point of view of an ICU nurse, some of this is the fault of administration. I can't count how many times in a day I have to go to the doc and say these words..."I know this is a non-issue, but policy says I MUST report it to you". An example, an 1 month old infant, s/p open heart surgery and ECMO X3 days. Develops a sternal wound infection and is in the ICU vented with an open chest and wound vac. All wound cultures negative, so started on Vanco and Gent. Per ID, we want Vanco troughs to be 10-15. Of course, to the lab, this is in the range of a critical alert. The lab calls to report to me a value of 13.1. Policy says I MUST report this to the MD. I go to the ICU doc and say, "I know this is exactly where we want this to be, but by policy I have to immediately report it to you". I have to chart the exact time the lab called me and the exact time I reported it to the MD. The time frame, by policy, is 10 mins. Does this not make me look like a nurse who doesn't know his patient? Have never worked in the ED, but am wondering if the same is true with the HTN issue?

On another subject, I also know exactly what you mean about PCP's sending their patients to the ED. However, I must also add that I also have some criticism for "SOME" ED Docs. Let me start by saying I work in a Pediatric ICU in a stand-alone children's hospital. Had a situation the other day that went like this:

Parents take their 3-week old infant to their pediatrician with c/o fussiness, no PO intake and no sleep X12 hrs. Significant for a 3 week-old. PCP examines the baby and notes a "slight tachycardia" so sends them to the ED....at a hospital that does not have pediatrics!! They contact our Cards attending on-call and give the same report and even add, "but the baby looks ok overall". We agree to accept the baby and ask that he be flown to us, since it could likely be a cardiac issue. The baby arrives to us, flight crew has intubated and administered Adenosine X3. On monitor, baby is in SVT with a rate of 350, CRT of 7-8 secs, unable to obtain BP and no peripheral pulses. Flight crew reports that this is the condition they found the pt in on arrival to the other hospital. The other hospital had not even put the baby on a monitor. Reported HR as >200 by apical ascultation. We started an aline to get a BP of 32/17. Administered adenosineX4, bolused and started an amiodorone drip and attempted to cardiovert X2. Here is my question...for an ER doc with little to no experience in Peds, is this what should be expected? Also, why would the pediatrician send the family to an ED without peds?

martygrn, if you're taking care of the kinds of patients you describe the answer is "no". You clearly know your stuff! I have a background in ECMO and know the level of dedication it takes to do what you do. 911 wasn't "dissing" you. It goes back to another issue.

To answer your question, it makes no sense for a pcp to send a kid to an ED without peds coverage. Those of us trained in EM seldom ever see kids like you describe (thank God). While they are "the norm" for you, they are a rarity in the non-specialty world, and though I can fault someone for not putting a monitor on a patient and having accurate vitals, I can't fault them too much for not knowing what to do next.

Thank God for people like you who fly in and help us with these patients!

my 'yes' to you simply meant that the lab messes with us just like the paper nurses and regulators mess with you.

i will slightly disagree with erdoc85, i think it's a huge miss for the kid not to be put on a monitor. at that point, even though we would not know what to do off the top of our heads, speaking personally, i would have pulled my pals reference, started lines, and followed the instructions, intubated, and called the helicopter.

as to why the pediatrician would send the child to the ER please see my theory on this here...

http://docsontheweb.blogspot.com/2007/06/whither-generalist.html

and as erdoc85 says, it was merely poor wording on my part. i most certainly was not criticizing you! you rock.

I was expecting some heart warming story about how ER docs' penises are so large that Path can tell one just by measurin' it. I got sucked in (hehe) to the comments which were all about circumcision. Here's my vote, trim that sh*t off!! Looks like a mole with it and smegma is a total turn-off. Despite what the internet claims.

Is Smegma useful? Yes, certainly. It lubricates the cavity between the foreskin of the penis and the glans, thus allowing smooth movement between them during intercourse. (Not in my woohoo)http://www.cirp.org/library/normal/wright1/Wellll now, inn't that speschal? Hmmm?